Citation Nr: 0023385
Decision Date: 08/31/00 Archive Date: 09/05/00
DOCKET NO. 95-13 442 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Buffalo,
New York
THE ISSUES
Entitlement to a rating greater than 30 percent disabling for
post-traumatic stress disorder (PTSD), prior to February 8,
1995.
Entitlement to an increased rating for PTSD, currently
evaluated 70 percent disabling.
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
W. R. Harryman, Counsel
INTRODUCTION
The veteran had active service from October 1966 to September
1968.
This case came before the Board of Veterans' Appeals (Board)
on appeal from a decision of the Department of Veterans
Affairs (VA) Regional Office (RO) in Buffalo, New York, in
August 1994 which denied an increased rating for PTSD, then
rated 30 percent disabling.
FINDINGS OF FACT
1. The evidence shows that, prior to February 8, 1995, the
veteran's PTSD was productive of considerable social and
industrial impairment.
2. The evidence shows that, from February 8, 1995, to May
11, 1999, the veteran's PTSD was productive of severe
impairment in the ability to establish and maintain effective
relationships and in the ability to obtain and retain
employment. His symptoms included occasional suicidal
ideation, significant depression that affected his ability to
function effectively, impaired impulse control, significant
difficulty adapting to stressful circumstances and in
establishing and maintaining effective relationships. He was
working essentially full time.
3. The evidence shows that, beginning May 11, 1999, the
veteran's PTSD rendered him unemployable.
CONCLUSIONS OF LAW
1. Prior to February 8, 1995, PTSD was 50 percent disabling.
38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R.
§§ 3.321(b), 4.1, 4.1, 4.7, 4.10, and Code 9411 (1996).
2. From February 8, 1995, to May 11, 1999, PTSD was not more
than 70 percent disabling. 38 U.S.C.A. §§ 1155, 5107(b);
38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.10, and Code 9411 (as
in effect prior to and beginning November 7, 1996).
3. Effective from May 11, 1999, PTSD was 100 percent
disabling. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R.
§§ 3.321(b), 4.1, 4.2, 4.7, 4.10, and Code 9411 (1996).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Factual background
The record shows that service connection was established for
anxiety reaction, effective from 1968. A noncompensable
rating was assigned initially. The rating was increased to
10 percent disabling by a rating decision in 1975. An
examiner in 1992 noted that the content of the veteran's
thought was significant for chronic intrusive thoughts of
traumatic events in Vietnam; the examiner diagnosed PTSD.
Noting that the medical evidence showed that the veteran had
been hospitalized for an increase in depression,
sleeplessness, anxiety, and fear of loss of control, a rating
decision in 1992 revised the service-connected disability to
PTSD and increased the rating for the disability to
30 percent, effective from May 1991.
VA outpatient records reflect weekly individual therapy
sessions during much of 1992 and 1993. PTSD symptoms that
were particularly troublesome to him at that time included
his social isolation, insomnia, nightmares, flashbacks,
irritability, and intense memories of Vietnam.
At the time of a clinic visit in August 1993, the veteran
denied recent depression, although he did appear anxious.
His energy, interest, and concentration were noted to be
good. There was no suicidal ideation or guilty rumination.
Although he still had nightmares, his sleep was improved with
low-dose trazodone.
A VA psychiatric compensation review examination was
conducted in June 1994. The examiner indicated that the
veteran's then-current complaints included depression,
anxiety, lack of sex drive, totally diminished libido,
intrusive thoughts about Vietnam, short temper, social
alienation, and a feeling of something crawling over his
skin. The veteran reported that he stayed by himself and had
a great deal of trouble being social with other people. It
was noted that he was last hospitalized for treatment for
PTSD in 1991. He was then employed as a train supervisor,
but reportedly had lost "major portions of time" from that
employment because of his PTSD symptoms. The examiner
recorded a Global Assessment of Functioning score of 55.
During a clinic visit in July 1994, the examiner reported
that the veteran had recurring nightmares and interrupted
sleep, and no close friends, although he was ok in
superficial relationships. He stated that he felt less
isolated being able to share Vietnam experiences and that his
sexual relationship with his wife had improved. In September
1994, the veteran reported an overall improvement in his
energy level, interest and concentration, but sleep was still
problematic.
An outpatient record dated February 2, 1995, indicates that
the veteran had experienced recurrent symptoms of depression
beginning approximately 2 months earlier, consisting of
feelings of hopelessness, decreased concentration, decreased
energy, insomnia, and anhedonia, as well as intermittent
suicidal ideation. The examiner increased the dosage of two
of the veteran's medications. On return visit in April 1995,
it was noted that his depression was moderately improved;
nevertheless, the examiner further increased the veteran's
psychotropic medications. The records show that the veteran
again had increased symptoms of depression beginning with the
death of his father in September 1995, and his increased
anxiety and depression related to that event continued well
into 1996 and even 1997. A report on November 9, 1995, notes
that there had been a significant increase in his symptoms
and the examiner increased his medication dosage.
In January 1996, a VA examiner indicated that the veteran's
symptoms of depression remained significant, but unchanged.
One March 1996 record notes that his depression and PTSD
symptoms had modestly improved, although he did still have a
"short fuse," while another March 1996 examiner reported
that he was still troubled by issues concerning his father's
death, and also had anxieties over his daughter's wedding and
his physical problems. A report dated in May 1996 states
that the veteran was showing the effects of increased stress,
e.g., occasional tearfulness, sleep disturbance, and anxiety.
An examiner in November 1996 indicated that, despite his
symptoms, the veteran was persevering and managing to hold
himself, his job, and his marriage together. Another
November 1996 examiner noted that the veteran reported having
more flashbacks and feeling more depressed.
In an April 1997 outpatient clinic note it was reported that
the veteran had a number of non-service-connected medical
problems. The examiner indicated that he stopped working
approximately 5 weeks previously because of his medical
problems (although another examiner in June 1997 noted that
he was still working at his job). The veteran also reported
having frequent anxiety episodes lasting approximately
45 minutes, both at home and while outside. The examiner
stated that the veteran's symptoms of depression and anxiety
were only partially treated; his medications were increased.
A VA psychiatric compensation examination was conducted in
December 1997. The examiner noted that the veteran was
employed as a railroad manager, earning approximately $70,000
per year. The veteran reported that his symptoms were
getting worse recently. They included flashbacks,
nightmares, short temper, being easily angered. On mental
status examination, there was no evidence of thought
blocking. His judgment and insight were adequate. He denied
any hallucinations, delusions, or other psychotic
symptomatology, and was not homicidal or suicidal. It was
noted that the veteran was receiving individual psychotherapy
2-3 times per month, but had ceased attending group therapy.
The examiner assigned a GAF score of 58. He commented that
the veteran was "employable, although only marginally, due
to PTSD symptoms. Unlikely he will be able to continue
working much longer due to PTSD."
The veteran's wife wrote in May 1998 regarding her
observations of the veteran. she stated that the veteran
continued to have recurrent recollections and dreams of his
combat experiences; his sleep disturbance was a continual
problem. She noted that he experienced feelings of loss of
control, vulnerability, defenselessness, recurrent intrusive
thoughts of the events in Vietnam, shame, doubts, and guilt.
His wife indicated that he avoided any social events because
of anxiety and angry reactions, and that he kept alone. She
stated that he experienced continued avoidance of activities,
sometimes memory impairment, and trouble concentrating.
An April 1998 outpatient report indicates that the veteran
was still grieving about his father's death. In May 1998, he
stated that he probably wouldn't be able to work much longer,
but feared that eventuality, seeing retirement as a prelude
to death. Records of other visits in 1998 and 1999 show that
he was easy to become teary-eyed when thinking about his
experiences in Vietnam; they also show problems with
claustrophobia which he related to an incident in Vietnam
when he was buried up to his neck after being shelled. He
was particularly anxious when he was seen in March 1999,
because his marriage was "in crisis." An April 1999 record
indicates that the veteran was having difficulty
concentrating, especially at work. Records dated in May 1999
reflect increasing marital difficulties and show that he was
off work.
Another VA psychological examination was conducted in July
1999. It was noted that the veteran had been on sick leave
from work since April 1999 due to his marital problems, which
exacerbated his PTSD symptoms, with resultant depression and
suicidal ideation. The veteran reported that his PTSD
symptoms had severely worsened over the previous several
months. He indicated that he had had to stop working as a
result of the exacerbation of his PTSD symptoms. In March
1999, he reportedly tried to commit suicide by taking an
overdose of his prescribed Ativan, but his wife stopped him
before he ingested a significant amount.
During the examination, the veteran was alert and cooperative
and his sensorium was intact. His speech was markedly
pressured, rambling, and tangential, however. He had
difficulty maintaining focus on the examiner's questions.
The veteran's thought processes were generally rational and
coherent, and there was no evidence of psychosis, delusions,
or hallucinations and no evidence of any severe confusion or
disorganization in his thinking. His mood was markedly
anxious and distressed and his affect was sad with multiple
episodes of tearfulness during the interview. There was
significant impairment of concentrations and short-term
memory. The examiner noted that the veteran presented with a
full range of PTSD symptoms, including twice weekly
flashbacks, frequent nightmares of combat, recurrent
intrusive and distressing recollections and obsessions of his
combat experiences that he has no control over, and intense
feelings of psychological distress and physiological
reactivity when he's exposed to any stimuli that remind him
of his Vietnam War experiences. He indicated that the
veteran made a concerted effort to avoid any contact with
thoughts, feelings, or conversations that may remind him of
those experiences. The examiner stated that the veteran
presented with evidence of marked social isolation, inter-
personal detachment, and psychic numbing. He displayed a
restricted range of affect, particularly in social and inter-
personal contexts. He also presented with a marked sense of
doom and negativity, indicating that he believed that he had
no future. The veteran reported an ongoing, severe sleep
disturbance and stated that, consequently, he was fatigued
throughout much of the day and that tended to exacerbate his
symptoms and increase his social isolation. He noted
episodes or irritability and anger, problems concentrating,
hypervigilance, and an exaggerated startle response. There
was also evidence of associated clinical depression.
The psychologist indicated that the veteran's insight and
judgment were generally good. There was no evidence of
psychotic disturbance, delusions, hallucinations, or
looseness of associations, although there was evidence of
frequent brooding and rumination. The examiner stated that,
in his opinion, the veteran was significantly impaired due to
his current PTSD symptoms and his marital problems. The
veteran indicated that he could do no more than some simple
daily chores around the house because of the stress level;
for example, he had someone else mow his lawn because he
could not deal with the lawnmower noise. The examiner noted
that the veteran was markedly socially isolated, as well as
marked claustrophobic tendencies. He concluded that the
veteran did not have "sufficient psychiatric stability" to
be "able to maintain himself in an adaptive manner in most
day-to-day social situations, nor in any typical day-to-day
work related situation ... it is possible that even with mild
to moderate improvement, the claimant could possibly attain a
level of functioning consistent with his returning to work."
He assigned a GAF score of 40.
VA outpatient records dated from the summer of 1999 and
through March 2000 show that the veteran's PTSD symptoms
waxed and waned somewhat, but he remained unable to return to
work.
Analysis
In general, an allegation of increased disability is
sufficient to establish a well-grounded claim seeking an
increased rating. Drosky v. Brown, 10 Vet. App. 251 (1997).
The Board finds that the veteran's claim concerning this
issue is well grounded. In addition, there is no indication
that there are additional, unsecured records that would be
helpful in this case. Therefore, the Board has no further
duty to assist the veteran in developing his claim.
38 U.S.C.A. § 5107(b).
Disability evaluations are assigned by applying a schedule of
ratings which represent, as far as can practicably be
determined, the average impairment of earning capacity.
38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Such evaluations
involve consideration of the level of impairment of the
veteran's ability to engage in ordinary activities, to
include employment. 38 C.F.R. § 4.10. Where there is a
question as to which of two evaluations should be applied,
the higher evaluation will be assigned if the disability
picture more nearly approximates the criteria required for
that rating; otherwise, the lower rating will be assigned.
38 C.F.R. § 4.7 (1999).
Although regulations require that, in evaluating a given
disability, that disability be viewed in relation to its
whole recorded history, 38 C.F.R. §§ 4.1, 4.2, the present
level of disability is of primary concern. Francisco v.
Brown, 7 Vet. App. 55 (1994). In evaluating the veteran's
claim, all regulations which are potentially applicable
through assertions and issues raised in the record have been
considered, as required by Schafrath v. Derwinski, 1 Vet.
App. 589 (1991).
In November 1996, during the course of the veteran's appeal,
VA adopted revised criteria for evaluating mental disorders.
The United States Court of Appeals for Veterans Claims
(Court) has held that, in such instances, a veteran's claim
must be evaluated under the provisions of both sets of
criteria, applying the criteria that are more favorable to
the veteran. Karnas v. Derwinski, 1 Vet. App. 308 (1991).
However, a precedent opinion by VA's General Counsel,
VAOPGCPREC 3-2000, held that, although all of the evidence
must be considered under both sets of criteria, a higher
rating assigned on the basis of the revised criteria cannot
be effective prior to the effective date of the revised
criteria.
The rating criteria for mental disorders that were in effect
prior to November 7, 1996, were as follows:
Under the general rating formula for psychoneurotic
disorders, a noncompensable evaluation is assigned when there
are neurotic symptoms which may somewhat adversely affect
relationships with others, but which do not cause impairment
of working ability. A 10 percent evaluation is warranted
where there is emotional tension or other evidence of anxiety
productive of mild social and industrial impairment. Where
there is definite impairment in the ability to establish or
maintain effective and wholesome relationships with people
and the psychoneurotic symptoms result in such reduction in
initiative, flexibility, efficiency and reliability levels as
to produce definite industrial impairment, a 30 percent
disability evaluation will be assigned. A 50 percent
disability evaluation is for assignment where the ability to
establish or maintain effective and wholesome relationships
with people is considerably impaired and, by reason of
psychoneurotic symptoms, the reliability, flexibility and
efficiency levels are so reduced as to result in considerable
industrial impairment. When the ability to establish and
maintain effective or favorable relationships with people is
severely impaired, and there are psychoneurotic symptoms of
such severity and persistence that there is severe impairment
in the ability to obtain and retain employment, a 70 percent
evaluation is appropriate. A 100 percent evaluation requires
either that (1) the attitudes of all contacts except the most
intimate be so adversely affected as to result in virtual
isolation in the community, or (2) that there be totally
incapacitating psychoneurotic symptoms bordering on gross
repudiation of reality with disturbed thought or behavioral
processes associated with almost all daily activities, such
as fantasy, confusion, panic and explosions of aggressive
energy resulting in profound retreat from mature behavior, or
(3) that the veteran be demonstrably unable to obtain or
retain employment. 38 C.F.R. Part 4, Code 9411 (1996).
As stated above, the criteria for a 30 percent evaluation
require "definite" social and industrial impairment. In
Hood v. Brown, 4 Vet. App. 301 (1993), the Court stated that
the term "definite" is "qualitative" in nature, whereas
the other terms used to rate mental disorders are
"quantitative" in character, and invited the Board to
"construe" the term "definite" in a manner which would
quantify the degree of impairment.
In a subsequent precedent opinion, VA's General Counsel
concluded that "definite" should be construed as meaning
"distinct, unambiguous, and moderately large in degree."
As used in rating mental disorders, it represents a degree of
social and industrial inadaptability that is "more than
moderate but less than rather large." VAOPGCPREC 9-93. The
Board is bound by this interpretation. 38 U.S.C.A.
§ 7104(c).
Effective November 7, 1996, VA's rating schedule provided as
follows:
When evaluating a mental disorder, the rating agency shall
consider the frequency, severity, and duration of psychiatric
symptoms, the length of remissions, and the veteran's
capacity for adjustment during periods of remission. The
rating agency shall assign an evaluation based on all the
evidence of record that bears on occupational and social
impairment rather than solely on the examiner's assessment of
the level of disability at the moment of the examination.
38 C.F.R. § 4.126 (1999).
For total occupational and social impairment, due to such
symptoms as: gross impairment in thought processes or
communication; persistent delusions or hallucinations;
grossly inappropriate behavior; persistent danger of hurting
self or others; intermittent inability to perform activities
of daily living (including maintenance of minimal personal
hygiene); disorientation to time or place; memory loss for
names of close relatives, own occupation, or own name, a
100 percent rating is appropriate. When there is
occupational and social impairment, with deficiencies in most
areas, such as work, school, family relations, judgment,
thinking, or mood, due to such symptoms as: suicidal
ideation; obsessional rituals which interfere with routine
activities; speech intermittently illogical, obscure, or
irrelevant; near-continuous panic or depression affecting the
ability to function independently, appropriately and
effectively; impaired impulse control (such as unprovoked
irritability with periods of violence); spatial
disorientation; neglect of personal appearance and hygiene;
difficulty in adapting to stressful circumstances (including
work or a worklike setting); inability to establish and
maintain effective relationships, a 70 percent evaluation in
warranted. Occupational and social impairment with reduced
reliability and productivity due to such symptoms as:
flattened affect; circumstantial, circumlocutory, or
stereotyped speech; panic attacks more than once a week;
difficulty in understanding complex commands; impairment of
short- and long-term memory (e.g., retention of only highly
learned material, forgetting to complete tasks); impaired
judgment; impaired abstract thinking; disturbances of
motivation and mood; difficulty in establishing and
maintaining effective work and social relationships, warrants
a 50 percent rating. With occupational and social impairment
with occasional decrease in work efficiency and intermittent
periods of inability to perform occupational tasks (although
generally functioning satisfactorily, with routine behavior,
self-care, and conversation normal), due to such symptoms as:
depressed mood, anxiety, suspiciousness, panic attacks
(weekly or less often), chronic sleep impairment, mild memory
loss (such as forgetting names, directions, recent events), a
30 percent evaluation is indicated. For occupational and
social impairment due to mild or transient symptoms which
decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by continuous medication, a 10 percent rating is
appropriate. If a mental condition has been formally
diagnosed, but symptoms are not severe enough either to
interfere with occupational and social functioning or to
require continuous medication a 0 percent evaluation is to be
assigned. 38 C.F.R. § 4.130.
Rating greater than 30 percent prior to February 8, 1995
The evidence shows that the veteran worked as a manager for a
railroad until 1999. Although he stated at the time of the
June 1994 VA examination that he had lost "major portions of
time" from his job due to his PTSD symptoms, the record does
not reflect that his employer made any concessions or
accommodations to the veteran because of that disability
prior to February 1995. The June 1994 examiner did record
significant PTSD symptomatology, however, and assigned a
Global Assessment of Functioning score of 55. That score is
commensurate with moderate symptoms and appears to be
consistent with the type and severity of the PTSD symptoms
that were reported by the June 1994 examiner. Although a
July 1994 clinic record indicates that the veteran had noted
improvement in some aspects of his PTSD symptoms, most of the
symptoms reported at that time were essentially as recorded
by the June 1994 examiner.
Inasmuch as a higher rating cannot be assigned prior to
November 1996 on the basis of the revised rating criteria,
the Board finds that application of the revised rating
criteria to this issue is not appropriate.
However, considering the criteria that were in effect prior
to November 1996, the Board finds that the recorded
manifestations of the veteran's PTSD prior to February 1995
more nearly approximated those contemplated by considerable
impairment in establishing or maintaining effective and
wholesome relationships and in the reliability, flexibility
and efficiency levels. Such a finding is also consistent
with a GAF score of 55 (indicating moderate symptoms), as was
assigned by the June 1994 examiner. In this regard, the
Board has considered the provisions of 38 C.F.R. § 4.7 and
also the benefit of the doubt provisions of 38 U.S.C.A.
§ 5107(b).
The Board finds, however, that the evidence does not show
that the veteran's PTSD was manifested by severe symptoms,
productive of severe social and industrial inadaptability, as
would be necessary for a higher rating of 70 percent
disabling. He was clearly working full time prior to
February 1995, apparently without much difficulty.
Neither does the evidence show that the manifestations of the
veteran's PTSD constituted such an exceptional case where an
evaluation provided by the rating schedule is inadequate.
There is no evidence that the veteran has been hospitalized
for treatment of his PTSD since 1991. Neither does the
record reflect marked interference with employment, despite
the veteran's statements regarding his PTSD necessitating
major portions of time off from work. He has submitted no
evidence of excessive time off from work due to the
disability or of concessions made by his employer because of
his PTSD. It should be noted that a high schedular rating
itself contemplates significant impact by the disability on
the veteran's ability to work. There simply is no evidence
of any unusual or exceptional circumstances that would take
the veteran's case outside the norm so as to warrant an
extraschedular rating under the provisions of 38 C.F.R.
§ 3.321(b).
Accordingly, the Board concludes that a 50 percent rating is
appropriate for the veteran's PTSD prior to February 1995.
Therefore, an increased rating to 50 percent disabling is
granted for that period.
Rating greater than 70 percent beginning February 8, 1995
The February 1995 outpatient record notes that the veteran
reported he had been experiencing increased symptoms due to
his PTSD, including hopelessness, decreased concentration,
decreased energy, insomnia, and anhedonia, as well as
intermittent suicidal ideation. Although there was some
periodic improvement and worsening in the veteran's symptoms
in 1995 and 1996, particularly following the death of the
veteran's father in September 1995, his symptoms clearly
remained at a higher level than he had previously
experienced.
The record indicates that the veteran did not work for a
brief period in 1997, but the reason for his not working was
reported to have been problems related to a number of non-
service-connected medical problems, rather than his PTSD.
His PTSD symptoms did remain at an increased level during
1997, however, on VA examination in December 1997, the
examiner stated that the veteran was employable, assigning a
GAF score of 58, indicating significant, but not totally
incapacitating symptomatology. The medical evidence, as well
as a statement by the veteran's wife, shows that the
veteran's PTSD symptoms also remained at a rather high level
throughout 1998. The 1998 records reflect repeated reference
to the veteran's desire to keep working as long as he could,
for fear he would die if he ever had to quit working.
In March and April 1999, the records reflect increased stress
in the veteran's marriage. He reported problems with
claustrophobia, but he apparently was still working at that
time. During a May 11, 1999, outpatient visit, however, the
examiner wrote that he discussed psychiatric hospitalization
with the veteran, but the veteran indicated that he felt it
wasn't needed at that time. The veteran was having
considerable problems with his marriage and the stress due to
his marital difficulties had increased his PTSD symptoms.
Although he was not suicidal or homicidal (his wife had
reportedly stopped a suicide attempt in March 1999, however),
the examiner did appear to have concerns in this area. It
was noted that the veteran was off work during the week of
that visit, but he indicated that he couldn't work anyway.
A VA psychologist in July 1999 reported continued very severe
symptoms due to the veteran's PTSD. That examiner assigned a
GAF score of 40. The Board notes that such a score is
consistent with being unable to work. The record does not
reflect that the veteran has been able to return to work
since May 11, 1999.
Based on the above evidence, the Board finds that the
veteran's PTSD rendered him unemployable, beginning May 11,
1999, the earliest date that the record indicates that he was
no longer working. The record does not reflect such severe
psychiatric symptomatology prior to that date as would
warrant a 100 percent schedular rating under either the
rating criteria that were in effect prior to November 1996 or
the revised criteria; as noted above, he was working
essentially on a full time basis prior to May 11, 1999.
Neither is there any evidence that the veteran's PTSD
presented such an exceptional disability picture prior to May
11, 1999, as would warrant an extraschedular rating under the
provisions of 38 C.F.R. § 3.321(b). The very high,
70 percent rating itself constitutes recognition that his
PTSD symptoms had resulted in a significant impairment in his
ability to work.
However, inasmuch as a 100 percent rating is warranted under
the old rating criteria if the veteran has been found to be
unemployable, the Board concludes that an increased rating to
100 percent should be assigned, effective from May 11, 1999,
the date that his unemployability was first ascertainable.
The Board has considered and applied the provisions of
38 U.S.C.A. § 5107(b) in this regard.
ORDER
An increased rating to 50 percent disabling for PTSD, prior
to February 8, 1995, is allowed, subject to the regulations
governing the award of monetary benefits.
A rating greater than 70 percent disabling for PTSD, from
February 8, 1995, to May 11, 1999, is denied.
A 100 percent rating for PTSD is allowed, effective from May
11, 1999, subject to the regulations governing the award of
monetary benefits.
C. W. Symanski
Member, Board of Veterans' Appeals